Spinning a Yarn: The Chronological Narrative

I was never explicitly taught to write documentation in school. It fell into the “They’ll train you how they want it when you’re hired” category, and all we got was a rough idea that there were a few common formats for writing your narratives.

I’ve experimented with a few different models, including the typical SOAP, CHART, and chronological formats. I don’t want to rehash the basics of how these work, because you’ve probably either learned about them or you will. However, on a regular basis I get coworkers peering over my shoulder and commenting on my own somewhat unusual style, so I thought I’d share it for anyone looking for something new.

The biggest change in my own narratives came when I moved to a service that wrote their documentation on computers. I have poor handwriting, write slowly, and don’t enjoy it; however, I’m a fast and comfortable typist, so once we switched from pencil to keyboard my narratives improved substantially. One of the early changes I made was a conscious effort to remove 99% of the abbreviations and shorthand; when typing, it’s usually just as fast to write it out fully, and it makes everything much more readable. (If you ever think to yourself that “everyone knows what YEOIOCRIPIDRN means,” attend M&M rounds sometime and listen to a room full of fellow EMS professionals try to puzzle it out.)

The goal with my narratives is to produce an easily readable, standalone document that tells the story of the call in a similar order to how I experienced it. Because our electronic PCR software includes separate sections to record details of the physical exam, vital signs, and so forth, I’m able to omit many of the nuts and bolts. What I do mention explicitly is all unusual findings, pertinent negatives, and whatever mundane details are necessary to knit the story together. One of the risks with the free-form chronological narrative is forgetting to include this or that assessment finding, but fortunately the ePCR prompts me for these things in other screens. Typically for EMS, documentation is one-half a record of patient care and one-half covering our butts; so although I try to minimize it, I also include some amount of standard butt-covering. This should be customized to what issues your own employer happens to care about. (I had one that insisted every patient be covered with two wool blankets in the winter; so, guess what ended up in the paperwork.)

I modeled my template on the discharge notes you find in hospital charts. I always found these to be pleasantly readable and professional; particularly if you start with the ED and admission note, read the hospital course, and finally the discharge summary, you have a great top-to-bottom view of what’s going on with the patient. I write chronologically, because it keeps the story understandable and because it allows me to show the order that things occurred, which is a central part of many calls; for example, we did X treatment, but then the patient began complaining of Y, so we changed things up to Z treatment — very different from if we’d known about Y from the beginning. However, I don’t adhere zealously to the timeline if it’s not especially relevant, so I’ll often group together assessment or treatment items for efficiency; as a result it’s often not too different from a loose SOAP or CHART format.

I’ll give three examples of hypothetical calls here: one routine transfer, one typical medical emergency, and one critical trauma call. This will seem wordy, but for many unremarkable calls the majority of the narrative can be written prior to arrival, simply leaving blanks for the bits you don’t know, then filling them in and fixing anything unexpected afterwards. (It’s helpful to understand how the actual PCR will print out once it’s completed and [in our case] faxed; this lets you know how it reads, what inserts where, and so on.)

Arrived on floor and met by staff, who provide paperwork/signature/report. Patient is Mr. Jeeves, a 73 yo male with hx of COPD and CHF, who presented with chest pain and dyspnea. He was found negative on cardiac enzymes with nonspecific ECG changes, admitted for further monitoring, and eventually underwent cardiac catheterization with no acute occlusions found. He is now stable and is being discharged to short-term rehab for gait training.

He is found in bed, alert and semi-Fowler’s, fully oriented with some general confusion, and denying acute complaints. There is some peripheral pallor, and non-pitting edema of the lower extremities. Vitals unremarkable, as noted above [note: in our ePCR, the vitals screen prints out above the narrative]. A locked IV is present in his left forearm.

He is transferred to our stretcher, secured with straps x5 and rails x2, and loaded onto A56. Transport routinely with monitoring en route. No changes in status during transport.

Arrived without incident, offloaded, and brought Mr. Jeeves to his room. He is transferred into bed and left in a low position, rails up, with his call button and belongings. His care and paperwork are transferred to staff.

Dispatched emergent to apartment in Malden for abdominal pain.

Arrived on scene to find Malden FD and PD with an adult female seated, alert. She is Ms. Bergerac, a 66 yo female with hx of NIDDM, who awoke 2 hours prior with general nausea, weakness, and abdominal pain. She describes the pain as 5/10, dull and diffuse, with a gradual onset over the past several days; she states the nausea has been ongoing over the same period, with the weakness new since this morning. She states she has been taking her normal meds, but has not eaten since yesterday due to the nausea. She denies vomiting, chest pain, dyspnea, headache, or parasthesias, and states she has felt normal with no unusual events up until several days ago. She denies any falls or other trauma.

She presents as fully oriented but slightly obtunded and slow to respond, and somewhat ill in appearance. Her pupils are midsize and PERL, and her lungs are clear and equal bilaterally. Abdomen is supple and non-tender with no visible discoloration, distention or mass. She is negative for arm drift, facial droop, or speech slurring, and demonstrates equal and unremarkable CSM x4. She is tachypneic, with an irregularly irregular radial pulse; her BGL is 46.

She is given 15g of oral glucose, which she tolerates well, and is transferred to our stairchair. She is brought outside, then transferred to our stretcher, where she is secured with straps x5 and rails x2. She is loaded onto A80 and transported non-emergent to House of God Medical Center with continuing assessment en route.

Repeat vitals note a BGL of 60 and minor increase in pulse. No other changes during transport.

Arrived without incident, offloaded, and brought Ms. Bergerac into the ED. She is transferred to a bed and left with rails up. Care transferred to RN with report.

Dispatched emergent to Denmark St. and Mulvaney Rd. in Waltham for an MVA.

Arrived with Waltham FD to find two vehicles in the center of the road. A small sedan has a heavily damaged back end with 2ft of compression; a midsize SUV is behind it with a broken windshield and crushed front left wheelwell. An adult male is found ambulatory, who states he was the driver of the sedan, with no apparent injury and denying any complaints. He states that he needs no care but wants his son evaluated, a teenaged male still in the front passenger seat, who also appears well and denies complaints. The father states they were struck from behind at unknown speed while stopped at a light. Both occupants endorse restraints, and there is no gross intrusion or airbag deployment. They are left in care of FD and a second unit is requested for further care.

An adult male is found in the driver’s seat of the SUV, slumped to the right against his seatbelt. He groans to painful stimulus but does not rouse. His skin is pale and cool, respirations are slow and irregular at 8/min, and radial pulse is thready and regular at 124. Breath sounds are grossly clear and equal. Oxygen is provided at 15LPM by NRB. An open abrasion is present on his left forehead, with blood found on the left upright support. There is no other obvious external trauma. A frontal airbag is deployed. There is starring of the windshield, seemingly from the airbag, and no other interior damage. ALS is requested.

The patient is manually stabilized and a C-collar is applied; he is rapidly extricated, exposed, and fully immobilized to a long spine board. He is placed on our stretcher and secured with straps x5 and rails x2, then loaded onto A104. (A11 arrives and assumes care of the other patients; see their runsheet for further.) Transport emergently to Intergalactic Trauma Center with continuing assessment en route.

Bleeding from the head wound is minor. There is diagonal bruising of the chest consistent with seatbelt trauma, and no other major bleeding or deformity. The trachea is midline and there is no appreciable JVD. Chest rise is equal bilaterally, the ribs are stable, and the abdomen is supple and without distension. Vitals note a BP of 184/100, HR 80, and increasingly shallow respirations at 6/min. A grossly dilated right pupil is also noted to develop en route. An OPA is inserted and well-tolerated. Ventilations are assisted by BVM with mild hyperventilation at a rate of 20/min.